Provider Demographics
NPI:1306410279
Name:PARKS, EDWARD KARL
Entity Type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:KARL
Last Name:PARKS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 632
Mailing Address - Street 2:
Mailing Address - City:PRATHER
Mailing Address - State:CA
Mailing Address - Zip Code:93651-0632
Mailing Address - Country:US
Mailing Address - Phone:559-707-7007
Mailing Address - Fax:
Practice Address - Street 1:1396 W HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-7126
Practice Address - Country:US
Practice Address - Phone:559-417-7616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-16
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT125178106H00000X
106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist